Medication adherence: Social and behavioral factors (External)

Of the six major buckets identified by RxLive that categorize medication adherence — cost; side effects; skills; understanding and knowledge; social and behavioral factors; access to care and burden of regimen — the social and behavior bucket is one of the most dense, including both internal and external factors. 

Social and behavioral factors that influence medication adherence include lack of motivation; challenges with provider-patient relationships; social and family support; lifestyle; negative beliefs pertaining to the treatment and monitoring plan, healthcare system or diagnosis; or psychological problems. 

Continuing our multi-part series of blogs regarding the impacts on medication adherence, this post is the second of a two-part “mini-series” examining how social and behavioral factors can affect medication adherence. This post covers external motivators; also see our post on internal factors.

External social and behavioral factors: Influence on medication adherence

 

Social and behavioral external factors are those for which patient’s don’t have direct control but which h affect their health-related actions — provider-patient relationships, social and family support, and psychological problems.

As described in The Self-Determination Theory (SDT), relatedness is a physiological need that influences motivation and behavior, referring to connectedness with others. Literature such as this published by The Mayo Clinic shows that patients with positive provider relationships and connection have higher rates of medication adherence. 

The patient-physician relationship is the result of a contract, explicit or implied, between a patient and physician (as well as others on their team) that makes the patient feel comfortable with the professional treatment they’re receiving according to what they understand are the ethical principles of medicine. This includes the feeling of being listened to as a pivotal member of the care team who brings personal knowledge of the symptoms being experienced. 

Erosions in this relationship can result when a patient doubts the fundamental concepts of the contract. Relationship challenges with providers can arise from lack of provider trust, care provided by multiple providers that can seem disconnected or even contradictory, limited communication in general, a lack of comfort or physician rapport, and brief doctor visits that can make the patient feel marginalized and that minimizes the sharing of pertinent information. A weak patient-provider relationship can negatively impact adherence, prompting patient behavior that doesn’t follow the prescriber’s recommendations.

Social and family support within homes, broader families, schools, workplaces, neighborhoods, social groups and whole communities can improve medication adherence. These social determinants of health (SDOH) are non-medical healthcare factors that can positively or negatively affect health outcomes. As the Journal of General Internal Medicine points out, studies show that patients have increased adherence rates when in homes with other family members taking medications, acting as a support system for each other. A literature review published in The American Journal of Managed Care reported social or familial networks that provide emotional and practical support may significantly impact medication adherence. Such support can assist patients in overcoming barriers such as poor health literacy, skills challenges, cost barriers, behavioral issues, or assess burdens. 

Psychological problems such as depression, psychosis, stress disorders and apathy can impact medication adherence due to limitations from the conditions. Motivational issues, potential skills problems, and health literacy challenges can occur secondary to psychological disorders which may be exacerbated by deficits in social support or cost struggles. 

How pharmacists can improve medication adherence regarding external social and behavioral factors

 
  • Repairing patient/provider relationship challenges — Though it’s important for providers to also play an essential role, RxLive pharmacists work to uncover barriers to medication adherence, including what they perceive as relationship issues with their provider and his or her office team. Through our patient consults using motivational interviewing (MI) as part of our medication therapy management (MTM) program and its repetitive counseling sessions, we work to enable patients to prepare for physician appointments. This includes helping them create a list ahead of their visit, prioritizing their problems, and taking notes during the visit and thus acting as a well-prepared collaborator in their health regimen. We encourage patients to feel empowered to ask their provider about areas where the patient still has questions or concerns. Satisfaction and trust will grow when patients exit appointments feeling their needs have been fully addressed.
  • Social and family support challenge — Clinical pharmacists help patients “drill down” to thoughtfully identify and leverage their existing social and family networks; this enables them to follow-up to receive practical support with items that can impede or improve medication adherence, such as transportation, filling pill boxes, and reading labels. Using MI, patients can be motivated and empowered to repair or grow emotional support from their existing networks, and be encouraged to seek additional external social networks — live and/or online — for further practical and emotional support. We strive to provide recommendations to social support groups and programs as needed.
  • Negative beliefs about the treatment and monitoring plan, healthcare system, or diagnosis — Both our clinical pharmacists and other members of patients’ care team should be sensitive to helping enable patients to identify and transform their negative beliefs through empathetic listening and MI. We have what is designed to be a non-threatening discussion to discuss current beliefs, uncovering why negative views exist. It’s also needed to offer knowledge-based professional reasoning on how their medications work to thwart disease progression, dispelling fears about addiction, side effects, lack of faith in medications, and discuss self-monitoring techniques or alternatives. It’s helpful in this process to help patients recall positive experiences they’ve had in the healthcare system. That can be further strengthened by pointing to research, innovations, situations and effective ways to improve patient choice and empowerment, rapid access, and positive statistics to build confidence and trust in the system. We work to help motivate patients to find hope and support for their illness or condition through family, physician, pharmacist, social groups and pertinent community services.
  • Psychological problems — An important aspect of our clinical pharmacists’ consuls is to identify whether a patient can benefit from MI or how their social determinants of health can positively or negatively impact their adherence. We use the teach-back method to instruct and reinforce how to follow their medication regimen, administer medications, or use devices. And we are quick to notify patients’ providers if the psychological condition has characteristics that require further monitoring and support in a medical setting, and collaborate as necessary to maximize patients’ adherence.

Summary

 

Medication adherence is affected by several factors in the social and behavioral bucket categorized by RxLive that can further be separated into external and internal influences. Through motivational interviewing and repetitive counseling, pharmacists can address provider-patient relationships challenges; social and family support; psychological problems; lack of motivation; lifestyle; negative beliefs pertaining to the healthcare system, or a diagnosis, treatment and/or monitoring plan. 

Social and behavioral factors aren’t easily identified, but pharmacists are in a trusted and accessible position, with knowledge and tools that make them uniquely qualified to increase medication adherence pertaining to this adherence bucket.

Related medication adherence blogs

Social and behavioral factors (internal)

Understanding and knowledge (health literacy)

Skills

Impact of cost

Resources

 

Association Between Different Types of Social Support and Medication Adherence. AJMC

Can We Improve Patient Adherence by Harnessing Social Forces? JGIM

Medication Adherence: WHO Cares? Mayo Clin Proc

Author avatar
Kristen Engelen, PharmD
Kristen Engelen, PharmD, is the chief pharmacy officer of RxLive and a certified consultant pharmacist; she has over a decade of experience in retail pharmacy settings. Kristen became an RxLive co-founder because of her passion for geriatric pharmacy, with a focus on the intersection of pharmacy and aging.